What is the best next medication adjustment for a 90-year-old patient with chronic pain due to a nonunion fracture of the shoulder and knee osteoarthritis (OA) who remains symptomatic despite hydrocodone (Hydrocodone) 4.5mg orally twice daily (BID) and hydromorphone (Hydromorphone) 2mg once in the afternoon?

From the Guidelines

I recommend increasing the hydromorphone dose to 2mg twice daily (morning and afternoon) while maintaining the current HM Contin (hydromorphone controlled-release) 4.5mg twice daily, as this approach allows for better coverage of breakthrough pain throughout the day while minimizing the risk of side effects that might occur with increasing the long-acting opioid 1. For a 90-year-old patient with chronic pain from a nonunion shoulder fracture and knee osteoarthritis who continues to experience inadequate pain relief, a modest increase in the immediate-release opioid component is appropriate before adjusting the long-acting medication.

Considerations for Medication Adjustment

• In elderly patients, medication adjustments should be made gradually with close monitoring for adverse effects such as sedation, confusion, constipation, and respiratory depression.
• The patient's current opioid regimen includes HM Contin 4.5mg po BID and hydromorphone 2mg once in the afternoon, which may not be providing adequate pain relief.
• Increasing the hydromorphone dose to 2mg twice daily may provide better pain control while minimizing the risk of side effects associated with increasing the long-acting opioid.

Non-Opioid Adjuvant Therapies

• Ensure the patient is using appropriate non-opioid adjuvant therapies such as acetaminophen (if not contraindicated), topical analgesics, and non-pharmacological approaches like physical therapy and heat/cold therapy to complement the opioid regimen.
• Regular reassessment of pain control, function, and side effects is essential in this age group.

Opioid Conversion and Titration

• According to the study by 1, hydromorphone has a relative effectiveness of 7.5 compared to oral morphine, and the maximal daily dose is not limited, but caution is advised when switching to another opioid due to individual variability in response.
• The study by 1 highlights the importance of gradual titration and close monitoring when adjusting opioid medications in elderly patients with chronic pain.

Monitoring and Follow-Up

• If the adjustment doesn't provide sufficient relief after 3-5 days, consider increasing the HM Contin to 6mg twice daily, with continued close monitoring for adverse effects.
• Regular follow-up appointments are crucial to assess the patient's response to the medication adjustment and make further adjustments as needed.

From the FDA Drug Label

2 DOSAGE AND ADMINISTRATION

1. 5 Titration and Maintenance of Therapy Individually titrate hydromorphone hydrochloride tablets to a dose that provides adequate analgesia and minimizes adverse reactions Continually reevaluate patients receiving hydromorphone hydrochloride tablets to assess the maintenance of pain control and the relative incidence of adverse reactions, as well as monitoring for the development of addiction, abuse, or misuse If the level of pain increases after dosage stabilization, attempt to identify the source of increased pain before increasing the hydromorphone hydrochloride tablets dosage If unacceptable opioid-related adverse reactions are observed, consider reducing the dosage. Adjust the dosage to obtain an appropriate balance between management of pain and opioid-related adverse reactions.

The best next medication adjustment for the patient is to titrate the hydromorphone dosage to achieve adequate analgesia while minimizing adverse reactions.

• Consider increasing the dosage of hydromorphone, but cautiously and with close monitoring for signs of excessive sedation and respiratory depression.
• Alternatively, consider adding a supplemental dose of 5 to 15% of the total daily usage every two hours on an as-needed basis.
• Before making any changes, attempt to identify the source of increased pain and consider other factors that may be contributing to the patient's pain. 2

From the Research

Medication Adjustment Options

The patient is currently taking HM contin 4.5mg po BID and hydromorphone 2mg once in the afternoon, but still complains of pain. Considering the patient's age and chronic pain conditions, the following options can be considered:

• Increasing the dose of hydromorphone, as it is already being used and the patient may benefit from a higher dose 3
• Adding or substituting with another opioid, such as buprenorphine, fentanyl, morphine, or oxycodone, which are considered suitable for elderly patients with chronic pain 3
• Considering the use of controlled-release oral dosage forms or transdermal formulations to improve convenience for the patient 3

Factors to Consider

When making medication adjustments, the following factors should be taken into account:

• Age-related decline in organ function and potential for drug-drug interactions 4, 3
• The patient's individual response to opioids and potential for adverse effects 5, 6
• The importance of individualized pain treatment and the need to balance pain relief with potential side effects 7

Potential Next Steps

Based on the available evidence, potential next steps could include:

• Consulting with a pain management specialist to determine the best course of treatment for the patient
• Conducting a thorough review of the patient's medication regimen to identify potential drug-drug interactions and optimize therapy
• Considering the use of non-pharmacological treatment options, such as physical therapy or cognitive-behavioral therapy, to complement pharmacological treatment 7